1. Alergology and Clinical Immunology training in Portugal Mário Morais-Almeida Sociedade Portuguesa de Alergologia e Imunologia Clínica UEMS Allergology Section and Board Meeting Lisbon, 29 November 2009

2. Just as in other countries, an empirically applied approach to allergology and immunology related diseases (clinical history, skin prick tests, specific immunotherapy) 1950: Portuguese Society of Allergy (future Portuguese Society of Allergology and Clinical Immunology - SPAIC)

3. 1960s and 70s: –The start of specialisation, and the first hospital unit –The setting up of more Allergology and Clinical Immunology hospital units … research – the first steps of the specialisations to autonomy Lisbon, Coimbra, Porto Vila Nova de Gaia Algarve Madeira Setúbal Covilhã Évora Azores …

4. 1983: Specialisation in Allergology and Clinical Immunology (Portuguese Medical Association) 1986: Specialisation in Allergology and Clinical Immunology (Portuguese Ministry of Health) The 1980s: –The first Allergology and Clinical Immunology residents (1987) –Hospital units / departments –Research –Post-graduate courses (…SPAIC)

5. The specialisation of Allergology and Clinical Immunology aims to prevent, diagnose, treat and rehabilitate all age groups of patients suffering from allergology and clinical immunology conditions (including respiratory, ocular, skin, digestive, medicinal and food allergy, hymenoptera venom, workplace-related, anaphylaxis, immunodeficiencies and auto-immune pathologies). A second aim is raising public awareness and understanding to bring about a sizeable drop in enviromental allergen exposure, in the home, workplace and community. DR, 1986

6. Residency in Allergology and Clinical Immunology 60 months: –Paediatric and Internal Medicine- 6 months each –Allergology and Clinical Immunology - 37 months (including periods in paediatric and adult units) –Immunology Laboratory - 3 months –Pulmonology - 3 months –Dermatology - 3 months –ENT - 2 months (Official Gazette – Ministerial Despatch 417/86 of July 31) After medical school and 2 yrs of general training…

7. Residency in Allergology and Clinical Immunology 60 months: –Paediatric and Internal Medicine- - 9 months each –Allergology and Clinical Immunology - 30 months (including periods in paediatric and adult units) –Immunology Laboratory - 5 months –Pulmonolgy - 3 months –Dermatology - 2 months –ENT - 2 months (Official Gazette – Ministerial Despatch 327/96 of August 2) After medical school and 2 yrs of general training…

8. TRAINING IN ALLERGOLOGY AND CLINICAL IMMUNOLOGY 2004 / 2006 Training Revision – Allergology and Clinical Immunology Board, Portuguese Medical Association working together with SPAIC National and international (UEMS) requirements Proposal approved by the Portuguese Medical Association – 2006 (to be started in 2009) (included initial year, common to all specialities)

9. The aim of the residency in Allergology and Clinical Immunology is to acquire the theoretical and practical specialised knowledge and the techniques vital for ethical, competent and autonomous practice of the speciality, allowing the physician to contribute to an improved quality of life in the population. Single residency – initial and specialised training (general training of 12 months + specialisation)

10. Length of residency - 72 months General training ( Internal Medicine - 4 months; Paediatrics - 2 months; Obstetrics – 1 month; General Surgery - 2 months; General Practice and Public Health– 3 months) Paediatric Medicine - 9 months – Optional in Paediatric Intensive Care (2M) Internal Medicine - 9 months – Optional in Intensive Medicine (2M) Allergology and Clinical Immunology - 30 months - General Allergology and Clinical Immunology - 12 months - Paediatric Allergology and Clinical Immunology - 6 months - Adult Allergology and Clinical Immunology - 6 months - Final residency in Allergology and Clinical Immunology - 6 months Immunology Laboratory – 3 months Pulmonology - 3 months Dermatology - 3 months ENT - 3 months

11. 4 – Training places – Units / Departments with idoneity (OM) 5.14 – The intention is that at the end of the residency the trainee has undertaken solo throughout the trainning programme a minimum number of procedures set out below, aiming to acquire sufficient experience in terms of interpretation, fundaments, indications, limits, sensitivity, specificity, predictive value, factors of error and cost-benefit ratio.

12. 5.14... a)Personally accompanying AT LEAST 500 PATIENTS at Allergology and Clinical Immunology appointments and Personally performing and interpreting… b) … at least 250 skin tests, 50 intra-dermal tests, 50 epicutaneous tests; c)... at least 20 specific nasal challenge tests validated by clinical and/or functional evaluation; d)... at least 10 specific conjunctival challenge tests; e)... at least 100 basal respiratory functional studies, 50 bronchodilator with beta-2 mimetics and 20 non-specific bronchial challenge tests; f)... at least 20 oral food/additives challenge tests; g)... at least 20 drug challenge tests;

13. …Personally performing and interpreting… h)... at least 10 physical exercise challenge tests; i)... at least 10 physical stimulation challenge tests; j)... at least 100 subcutaneous applications of specific immunotherapy, in addition to the personal and direct responsibility for supervising at least 1000 subcutaneous administrations of immunotherapy performed by other health professionals 5.14...

14. K) Personally monitoring accelerated immunotherapy schemes in at least 5 patients; l)... At least 10 sessions of IV gamma globulin administration; m)... Suitable drug or food tolerance induction protocols in at least 5 patients; o) The public presentation of at least 10 oral and/or poster communications, original work in the Allergology and Clinical Immunology field at accredited national or international meetings; p) Publication (or accepted for publication with written proof) of at least 4 original articles in national or international Allergology and Clinical Immunology journals. n) A post-graduation course in basic and advanced cardio- respiratory reanimation (if no intensive medicine residency was opted for);

15. Encouragment to undertake part of the training at other specialised centres: National INTERNATIONAL Germany Spain France UK Denmark Finland USA Netherlands... Portuguese Society (SPAIC) GRANTS

16. Assessment: Continuous throughout the residency The weight of the performance evaluation criteria is: a) Technical execution capability - 4 b) Interest in professional development - 3 c) Professional responsibility - 2 d) Interpersonal workplace relationships - 1 Annual report* discussion and theoretical and practical evaluation Public final evaluation exams (2 days): Curricular* exam Clinical exam Theororetical exam * recomendations by the Immunoallergy Board OM

17. CRITERIA FOR DETERMINING CENTRES WITH TRAINING CAPACITY FOR COMPLYING WITH THE MEDICAL RESIDENCY TRAINING PROGRAMME IN ALLERGOLOGY AND CLINICAL IMMUNOLOGY Portuguese Medical Association - May 2007 (first revision)

18. Hospital Services or Units whose organisation and running of their own or shared in-patient and out- patient areas (including Day Hospital) meets the minimum requirements proposed by the Board of this Specialisation will be considered as being of good standing. This means particularly: They have technical and administrative autonomy and the Service or Unit is run by an specialist certified by the Allergology and Clinical Immunology Board, guaranteeing qualified, permanent responsibility; They have at least three Allergology and Clinical Immunology Board certified specialists as part of their permanent structure;

19. It is desirable that there is a one-to-one specialist- resident ratio. A two or three-to-one resident- specialist ratio is admissible although not recommended...; Assistance at at least 100 first appointments per year per resident, with a minimum of 500 first appointments per year with a varied age and condition range allows efficacious training in the specialisation; Each Service of Unit should be suported by suitable complementary means of diagnosis and treatment …

20. The Immunoallergology Medical Association Board shall verify annually if the Services and Units continue to comply with the predefined norms and may remove an establishments Good Standing status. September 2007 – last visit to all Services/Units; 2 Allergology and Clinical Immunology Board representatives + Portuguese Medical Association Board of Directors representative + Trainee representative May 2008 - full idoneity was conferred to a new health unit (1st private unit...)

21. ENT Dermatology Paediatrics General Practice Internal Medicine Pulmonology Allergology and Clinical Immunology Symposia Courses Newsletter PNCA Symposia International Meetings CG Training PNCA Observatory Symposia Courses Symposia Patients Associations Media ANF Industry

22. spaic@sapo.pt Portugal 1 public hospital specialist / 250,000 inhabitants 200 specialists in the OM Immunoallergology Board 32 residents in training 7 training centers SPAIC - 400 members